1、.是是第一类第一类证明能降低心衰死亡率的证明能降低心衰死亡率的药物药物 是心衰治疗的是心衰治疗的基石基石Cornerstone (E.Braunwald M.Bristow 1991,2000)是从阶段是从阶段A【前心衰【前心衰(pre-HF)阶段】阶段】D 每一阶段都推荐应用的药物每一阶段都推荐应用的药物.TrialACEIControlsRR(95%CI)CONSENSUS ISOLVD(Treatment)SOLVD(Prevention)Chronic CHFPost MISAVETRACEAIRE39%54%0.56(0.340.91)40%35%0.82(0.700.97)15%1
2、6%0.92(0.791.08)25%20%0.81(0.680.97)17%23%0.73(0.600.89)SMILE6.5%8.3%0.78(0.521.12)Average0.78(0.670.91)35%42%21%25%MortalityGarg R et al.JAMA.1995;273:14501456.Odds ratio(95%CI)220/3044(7.23%)570/9682(5.89%)2035/29,028(7.01%)676/7460(9.06%)CONSENSUS-II（依那普利）（依那普利）Test for Heterogeneity:2 5.8(2p=0.1
3、)df=3Deaths(n)/Randomized(n)GISSI-3（赖诺普利）（赖诺普利）ISIS-4（卡托普利）（卡托普利）CCS-1（卡托普利）（卡托普利）TotalControl O-E Variance1.01.251.50.750.5727/7489(9.71%)650/9712(6.69%)192/3046(6.30%)2171/29,022(7.48%)3501/49,214(7.11%)3740/49,269(7.59%)14.0739.0668.2224.14117.3596.05285.83975.33317.851675.06ACEIACEI betterContro
4、l betterOdds reduction(SD)7 2Treat Eff:2(2p=0.004).YearsProbability of Event00.050.10.150.20.250.301230.350.44 ACE-I 2995 2250 1617 892 223Placebo 2971 2184 1521 853 138OR:0.74(0.660.83,p0.0001)To avoid 1 death,15 pts would have to be treated for 30 monthsACE-I:702/2995(23.4%)Placebo:866/2971(29.1%)
5、TRACEEchocardiographicEF 35%AIREClinical and/or radiographic signs of HFSAVERadionuclideEF 40%.ARB仅用于仅用于ACEI不耐受时的替代不耐受时的替代.ESHESC Guidelines.J Hypertens 2007;25:11051187.Reduction in new diabetes(%)Adapted from Pepine CJ,Cooper-Dehoff RM.J Am Coll Cardiol 2004.Julius S et al.Lancet 2004.PEACE Trial
6、Investigators.N Engl J Med 2004.RAAS modulation reduces new-onset diabetesTreatment with ACE inhibitors or ARBsSCOPECHARMANBP2LIFEHOPEALLHATCAPPPSTOP-2VALUEPEACE-40-30-20-100.Number at riskAmlodipine perindopril 96399383 9165 89668726 7618Atenolol thiazide 96189295 9014 87358455 73190.01.02.03.04.05
7、.0Years0.02.04.06.08.010.0Amlodipine perindopril(No.of events=567)Atenolol thiazide(No.of events=799)HR=0.70(0.63-0.78)p 0.0001%.HOPE/HOPE-TOO Study Investigators.Circulation.2005;112:1339-46.1262401234810567PlaceboRamiprilYearsRRR 31%P=0.0006HOPE-TOO beginsMain HOPE study ends2883283728032763270426
8、722600258723922431181318531269132410211092New-onsetdiabetes(%HOPE-TOO patients)PlaceboRamipriln .Mancia G et al.J Hypertens 2007;25:1105-1187.贝那普利贝那普利 31/300安慰剂安慰剂 57/283年年0 1 2 3未达到终点的患者百分数未达到终点的患者百分数P0.01危险性降低危险性降低53%100%80%60%40%20%0%.贝那普利可改善多种病因肾脏疾病的肾存活贝那普利可改善多种病因肾脏疾病的肾存活贝那普利贝那普利对伴蛋白尿的肾脏病患者效果更好对
9、伴蛋白尿的肾脏病患者效果更好贝那普利贝那普利保护肾功能的同时能够降低血压及蛋白尿保护肾功能的同时能够降低血压及蛋白尿轻、中度肾功能不全（轻、中度肾功能不全（CrCI 30-60ml/minCrCI 30-60ml/min）的患者）的患者使用使用贝那普利贝那普利很安全很安全.对洛汀新对洛汀新治疗组病人与安慰剂组病人主要疗效指标（透析治疗、移植和肾脏疾病相关的死亡）比较的治疗组病人与安慰剂组病人主要疗效指标（透析治疗、移植和肾脏疾病相关的死亡）比较的Kaplan-MeierKaplan-Meier曲线。两曲线。两组的肾脏事件发生率自随机分组后的第组的肾脏事件发生率自随机分组后的第1515个月开始出
10、现差异，洛汀新个月开始出现差异，洛汀新组疗效明显（组疗效明显（P0.013)P0.013)。未达综合终点的病人百分数未达综合终点的病人百分数 0 1 2 3 4 5 6 7危险性降低危险性降低31%洛汀新洛汀新组组 79/300安慰剂安慰剂组组 102/283年年100806040200P0.013.061218243036100806040200RamiprilPlaceboP=0.02The GISEN Group.Lancet.1997;349:18571863.%of patients withoutcombined endpoint*Combined endpoint=doubling of baseline serum creatinine concentration or end stage renal failure.
